CARDIOVASCULAR MECHANICS BME 4570/BNG5232 FINAL EXAM Jan 14, 2014

There are eight questions in the exam. Each question has multiple sub-questions. Sub-questions are not equivalent. You will be graded over 200. Type your answers in this file, immediately under each question. Use as much space as you need for each answer. Use Times New Roman, 12 points in MS Word. Use the Equation and Symbols Toolbox (see Q-VIII). Show every step of your calculations. Pay attention to mark units for every variable or parameter. In M/C and T/F questions, explain how and why you picked your answer. This is required for full credit. THE EXAM IS TAKE HOME. YOU MAY CONSULT WITH OTHERS BUT YOU MUST WRITE ALONE. Return your answer file to my e-mail before Monday, January 20, 2014, by 24:00 hrs.

I pledge that I have answered all questions by my own, based solely on my own knowledge and understanding. Your Signature Your Name

Q-I 1 2 3 4 5 6 7 8 9 10 ___ 30

Q-II 1 2 3 4

Q-III 1 2 3 4 5 6

Q-IV 1 2 3 4 5 6 7 8 9 10 ___ 30

Q-V 1 2 3 4

Q-VI 1 2 3 4 5 6

Q-VII 1 2 3 4

Q-VIII 1 2

TOTAL

__ 15

___ 15

___ 30

___ 15

___ 30

___ 35

I-1. Which organ in the body always receives the most blood flow? Why?

The blood flow to a given organ or tissue is dependent, not only on its mass, but also its energy needs, in other words, what its doing. The brain of a 70 Kg man has a mass of only 1500 gm, about 2% of the total. But at rest the brain receives 750 mL/min, or 15% of his total cardiac output (750/5,000 = 0.15). The heart receives about 250 mL/min of the cardiac output, or about 5% of the total blood flow (250/5,000 = 0.05). the skeletal muscle, which is connected to and moves our bones so we can be active, with a mass of about 30 Kg, or 40% of the bodys total, at rest, receives only 15% of the cardiac output, or 750 mL/min. The remaining blood flow mostly goes to the liver and gastrointestinal system (25%), the kidneys (20%), the fat (5%), the bones (5%), the skin (5%), and the lungs (2.5%).[1]
I-2. When a heart valve does not close properly, a sound called a "murmur" can often be detected as the valve leaks. Would you expect a leaky aortic valve to cause a systolic or diastolic murmur? Diastolic I-3. Calculate cardiac output from the following data: Pulmonary arterial pressure = 20 mmHg Pulmonary venous pressure = 0 mmHg Pulmonary vascular resistance = 4 mmHg x min/L 5L/min I-4. Using the following data: Mean arterial pressure = 100 mmHg Mean venous pressure = 0 mmHg Blood flow to the muscle = 5 mL/min a. Determine the vascular resistance of a resting skeletal muscle Must receive about 750mL/min ? but 20 mmHg x min/L b. Assume that when the muscle is exercising, the resistance vessels dilate so that their internal radius doubles. If blood pressure does not change, what is the blood flow through the exercising muscle? 2 times larger vessel = 2^4 times higher flow b. What is the vascular resistance of this exercising skeletal muscle? 1.25 mmHg x min/L I-5. Whenever skeletal muscle blood flow increases, blood flow to other organs must decrease. True or false? Why? False. Vital organs must keep receiving same amount of blood to function. I-6. What direct cardiovascular consequences would you expect from an intravenous injection of norepinephrine?

Increase at heart rate. I-7. Individuals with high arterial blood pressure (hypertension) are often treated with drugs that block -adrenergic receptors. What is the rationale for such treatment? Reducing cardiac output so pressure reduces too. I-8. An individual has had the "flu" for 3 days with severe vomiting and diarrhea. How is this likely to influence his or her hematocrit? White blood cell count increases. I-9. Which of the following manipulations would produce the greatest decrease in blood flow through a given vascular bed? Why? a. halve the length of the capillaries b. double the viscosity of the blood c. halve the pressure gradient across the bed d. double the radius of the venules e. halve the radius of the arterioles I-10. Arteries play which of the following functional roles in the systemic vascular system? Why? a. as conduit vessels b. as capacitance vessels c. as resistance vessels d. as exchange vessels II-1. Because pulmonary artery pressure is so much lower than aortic pressure, the right ventricle has a larger stroke volume than the left ventricle. True or false? Why? What comes in must go out. II-2. Which of the following interventions will increase cardiac stroke volume? Why? a. increased ventricular filling pressure high preload b. decreased arterial pressure low afterload c. increased activity of cardiac sympathetic nerves high heart rate bu low sv d. increased circulating catecholamine levels high heart rate bu low sv

II-3. Increases in sympathetic neural activity to the heart will result in an increase in stroke volume by causing a decrease in end-systolic volume for any given end-diastolic volume. True or false?

Explain based on the diagram below. True. Heart pumps only half of the end-diastolic volume at rest. Increased sympathetic neural activitiy causes stronger contractions and pumps more blood.

II-4. With all other factors equal, myocardial oxygen demand will be increased to the greatest extent by which of the following? Why? a. increases in the heart rate b. increases in coronary flow c. increases in end-diastolic volume d. decreases in arterial pressure e. decreases in cardiac contractility

III-1. Given the following information, calculate cardiac output: Systemic arterial blood oxygen concentration, [O2]SA = 200 mL/L Pulmonary arterial blood oxygen concentration, [O2]PA = 140 mL/L Total body oxygen consumption, VO2 = 600 mL/min 10L/min III-2. If left ventricular end-diastolic volume is 150 mL and end-systolic volume is 50 mL, what is the ejection fraction? Is this "normal" for a resting adult? (100/150)*100 = 66% in normal range III-3. Which is the definition of cardiac "ejection fraction"? a. stroke volume expressed as a percent of cardiac output b. the ratio of the end-systolic volume to the end-diastolic volume c. the ratio of the end-diastolic volume to the end-systolic volume d. the ratio of stroke volume to the end-diastolic volume e. the ratio of the time spent in systole to the time spent in diastole III-.4. Describe the primary pressure abnormalities associated with a. aortic stenosis Systolic pressure gradient between LV and Aorta (LV hypertension) b. mitral stenosis Diastolic pressure gradient between LV and LA (LA hypertension) III-5. Given the following data, calculate the resistance to flow across this stenotic valve. Show calculations. Aortic pressures (systolic/diastolic) = 150/100 mmHg Left ventricular pressures (systolic/diastolic) = 150/2 mmHg Left atrial pressures (systolic/diastolic) = 50/32 mmHg Heart rate = 60 beats per minute Stroke volume = 50 mL/beat 148/50~=3 a. 3.0 L/min b. 6.0 L/min c. 100 mmHg d. 30 mmHg/L per minute e. 10 mmHg/L per minute III-6. A 75-year-old male patient is alert with complaints of general fatigue. His heart rate = 90 beats per minute and arterial pressure = 180/50mmHg. A diastolic murmur is present. Cardiac catheterization indicates that LV pressure = 180/20 mmHg and left atrial pressure = 10/3 mmHg (as peak systolic/end-diastolic). Which of the following is most consistent with these findings? Why? a. aortic stenosis b. aortic insufficiency c. mitral stenosis d. mitral insufficiency

e. right ventricular hypertrophy

IV-1. Given the following data, calculate an individual's total peripheral resistance (TPR): Mean arterial pressure, A = 100 mmHg Central venous pressure, PCV = 0 mmHg Cardiac output, CO = 6 L/min 100/6=16.6 IV-2. Whenever cardiac output is increased, mean arterial pressure must also be increased. True or false? Why? True, as long as the arterial resistance remains the same IV-.3. Estimate the mean arterial pressure when the measured arterial pressure is 110/70 mmHg. 90? IV-4. At rest a patient has a pulse rate of 70 beats per minute and an arterial blood pressure of 119/80 mmHg. During exercise on a treadmill, pulse rate is 140 beats per minute and blood pressure is 135/90 mmHg. Use this information to estimate the exercise-related changes in the following variables: a. stroke volume increases b. cardiac output increases c. total peripheral resistance (TPR) decrease IV-5. Which of the following is consistent with a normal mean arterial pressure but an abnormally high arterial pulse pressure? Why? a. low stroke volume b. high heart rate c. decreased total peripheral resistance d. increased arterial stiffness e. aortic valve Stenosis IV-6 In which of the following vessels do red cells move with the fastest speed (distance/time)? a. arteries b. arterioles c. capillaries d. venules e. veins IV-7. Which of the following will decrease the mean circulatory filling pressure? a. increased circulating blood volume b. decreased arteriolar tone c. increased venous tone IV-8. According to Starling's law, cardiac output always decreases when central venous pressure decreases. True or false? True IV-9. In a steady state, venous return will be greater than cardiac output when a. peripheral venous pressure is higher than normal b. blood volume is higher than normal

c. cardiac sympathetic nerve activity is lower than normal IV-10. What approaches might a physician logically pursue in an attempt to lower a patient's cardiac preload? Diuretics or nitrate

Consider the Figure above to answer questions on this page V-1 How is the decrease in skeletal muscle vascular resistance evident from the data presented in the Figure above? Pressure increase 1.25 times when flow increases 10 times. So resistance is decreased. V-2. Is a decrease in total peripheral resistance implied in the Figure?

Stroke volume is increased 0.72 times when pressure rise is 1.25 times more so resistance is increased V-3 What in the Figure implies increased sympathetic activity? Increase in CO,SV,HR V-4. From the information given in the Figure, a. Calculate the resting and exercising stroke volumes (SVs). 0.08 and 0.11 b. Calculate the resting and exercising end-diastolic volumes (EDVs). From ejection fraction c. Calculate the resting and exercising end-systolic volumes (ESVs). From ejection fraction d. Draw two superimposed P-V loops that show, as accurately as possible at rest and during exercise, how this exercise affects the left ventricular volumepressure cycle.

[2]

VI-1. What happens to hematocrit? a. during hypovolemic shock resulting from prolonged diarrhea increase b. during acute cardiogenic shock decrease c. during septic shock uncertain/decrease d. with chronic bleeding decrease VI-2. Left ventricular chamber enlargement with congestive heart failure increases the wall tension required to generate a given systolic pressure. True or false? Why? Elasticitiy diminished and it gets harder to fill in. LV hyperthrophy normalizes pressure overload by increasing wall thickness to radius. If hypertrophy were perfectly regulated by the mechanical signal using a typical feedback loop, changes in radius, thickness, and pressure would be orchestrated such that wall stress would be constantly normalized. However, this often does not occur. For example, a large myocardial infarction imposes a volume overload on the

remaining myocardium, and cardiac dilatation with an increase in LV mass rapidly occurs.4 Although the initial dilatation may be compensatory to maintain stroke volume, adverse remodeling often develops whereby the ventricle becomes progressively more spherical and wall stress increases, perpetuating the dilatation.[3] VI-3. Why are diuretic drugs often helpful in treating patients with congestive heart failure? get rid of excess fluid to reduce afterload VI-4. What is the potential danger of vigorous diuretic therapy for the patient with heart failure? The intent is to reduce the end-diastolic pressure (and therefore hydrostatic forces contributing to pulmonary congestion) without a significant fall in stroke volume. The judicious use of diuretics does not significantly reduce stroke volume and cardiac output in this setting, because the failing ventricle is operating on the flat portion of a depressed FrankStarling curve. However, overly vigorous diuresis can lower LV filling pressures into the steep portion of the ventricular performance curve, resulting in an undesired fall in cardiac output[5] VI-5. A 70-year-old, 70-kg patient has an ejection fraction of 70%. Left ventricular end-diastolic volume is 60 mL. Which of the following statements best fits these data? a. Stroke volume is approximately 70 mL. b. Left ventricular end-systolic volume is approximately 60 mL. c. Your patient may be severely hypovolemic. d. Your patient may be suffering from chronic systolic heart failure. e. These are normal values for someone this age. VI-6. Chronic systemic hypertension is usually accompanied by a chronic increase in a. cardiac output b. the heart rate c. arterial pulse pressure d. total peripheral resistance e. renal urinary output

VII.

At maximum exertion, the heart of a long-distance runner weighing 75 kg can pump up to 15 liters per min of blood at a mean arterial pressure of 150 mmHg, mean atrial pressure of 20 mmHg, and a heart rate of 150 beats per min. What is the 1. Stroke Volume (mL) 2. Stroke Work (Joules/beat) 3. Total cardiac work during a 1-h run (Joules) 4. Average cardiac power (Watts= Joules/sec) 5. Efficiency of the heart as a pump. Assume: i. The average oxygen consumption of the heart muscle is 75 ml O2/kg/min ii. Energy equivalent of oxygen, EE, is 20.3 J/ml O2 iii. The weight in grams of the heart per kg body weight in man is 5.88

VIII.

In the three-element WK model,

1. Derive the governing equation for v(t) (pressure) and i(t) (flow)

(1 +

) i(t) + CR1

i(t) = C

v(t) +

2. Show that, during diastole, the aortic pressure decay is given by

P (t) = Pes
Refrences 1-Blood Flow: How The Body Controls It So It Can Survive, January, 2013, Dr. Howard Glicksman http://www.arn.org/ 2- ajpheart.physiology.org

3- Clinical Cardiology: New Frontiers Left Ventricular Hypertrophy. Pathogenesis, Detection, and Prognosis Beverly H. Lorell, MD; Blase A. Carabello, MD Circulation. 2000, Circulation 102: 470-479 4- Wall stress and patterns of hypertrophy in the human left ventricle. W Grossman, D Jones, and L P McLaurin J Clin Invest. 1975 July; 56(1): 5664. 5- Pathophysiology of Heart Disease 1st edition, by Leonard S. Lilly 2010 Lippincott Williams & Wilkins